Building capacity of primary health care workers and clients on COVID-19: Results from a web-based training

Background Health care workers (HCWs) in the first line of care play critical roles in providing the correct information about the coronavirus disease to the community. The objective of the study was to determine the effect of virtual training on the knowledge, attitude, and preventive practices among PHC workers and their clients in the prevention and control of coronavirus disease. Methods A quasi-experimental intervention virtual training, using a before and after design amongst HCWs and clients was conducted at primary health care facilities in two Local Government Areas of Lagos State. The study instruments were pre-tested questionnaires for both HCWs and their clients. which investigated knowledge of symptoms, modes of disease transmission, methods of prevention, and preventive practices. Changes in knowledge, attitudes, and practices were compared pre-and post-intervention. The level of significance was set at p < 0.05. Results Sixty-three HCWs (out of 100 recruited at baseline) and 133 clients (out of the initial 226) completed the study. The mean ages of the HCWs and clients were 39.2±9.9 and 30.9±5.0 years respectively. At the baseline, the HCW’s knowledge was good in the domains of symptoms, modes of transmission, and preventive measures. The training led to a higher but not significant (p> 0.05) increase in the level of knowledge. Contact with trained HCWs was found to lead to significantly (P < 0.001) higher levels of knowledge, attitudes, and preventive practices. amongst clients. Conclusion The training was effective in improving the knowledge of both the trained HCWs and their clients.

written or verbal consent. If consent was waived for your study, please include this information in your statement as well Response. Ethical approval was obtained from the Health Research Ethics Committee of the Lagos State University Teaching Hospital (REFERENCE NO: LREC/06/10/1501). Written informed consent was obtained from all the participants after explaining the study's aim and objectives. (This was in the initial submission, lines 258-260) 4.In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability. Upon re-submitting your revised manuscript, please upload your study's minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories Response. Data set is now uploaded as an Excel sheet 5.Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article's retracted status in the References list and also include a citation and full reference for the retraction notice. Response. Two new references have been added (no 16 and 21) making 24.
B.Responses to Reviewers (Line numbers in red are as on the tracked changes document) 1.The statistical analysis in general is appropriate and rigorous. However one is curious to know why an "independent t-test" was used to measure differences in knowledge, attitude and practice (KAP) pre-and post-intervention instead of a "paired t-test"? Response. Line 269-272.The independent T test was used when we compared post training scores only for analysis of statistical association (Tables 4 and 5) but when we compared as on Table 3, the paired T test was used. This we believe is appropriate. "Associations between the socio-demographic characteristics of respondents and their post-intervention COVID-19 knowledge, attitude, and preventive practices were assessed using an independent sample t-test and one-way analysis of variance  Yes -all data are fully available without restriction   LGA has an estimated population of 460,000 residents. There is a mixture of public and private  A before and after quasi-experimental study approach was used to conduct the study amongst

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Two almost identical study instruments were used to obtain data. The first was a PHC workers 164 questionnaire and the other was a client questionnaire. Both were designed to elicit the 165 knowledge, attitudes, and preventive practices of COVID-19 among the respondents. The were assessed using a 5-point Likert Scale: "strongly disagree, disagree, neutral, agree, and 176 strongly agree". Preventive practice questions (n=9) elicited information on what respondents 177 did to prevent the disease such as hand washing, use of face masks, and physical distancing.

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The preventive practices domain was assessed using a 4-point Likert Scale: "always, often, 179 sometimes and never". The third part consisting of 6 questions was on vaccine acceptability.

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Face and content validity was done by the research team. The reliability coefficients of the 181 HCWs tool sub-scales were: knowledge, α = 0.63; attitude, α = 0.60; and practice, α = 0.86.

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The reliability coefficients for the clients' tool were: knowledge, α = 0.82; attitude, α = 0.67; 183 and practice, α = 0.80. Pre-testing of the study instruments was done amongst 20 HCWs in an 184 LGA not involved in the study and who met the eligibility requirements of the study. This 185 was done to test the flow of questions, and clarity of the questions to the interviewer.

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The project was carried out in three phases: baseline (pre-intervention), intervention, and post-188 intervention phases. The baseline survey was to determine the level of COVID-19 knowledge, 189 attitude, and practices among health workers using the pre-tested self-administered  The study outcomes were changes in the knowledge, attitudes, and preventive practices which 229 were scored. For the knowledge domain, each correct answer was assigned one mark and a 230 wrong answer zero. The maximum knowledge score of HCWs was 33. The attitude of the 231 HCWs was scored, the range was from one to five, and the maximum score was 45. The 232 preventive practices were scored, the range from one to four, and the maximum score for the 233 preventive practice domain was 36. Categorization of knowledge, attitudes and preventive 234 practices was done into good if the scores were at least 66%. 21 Scoring for the clients was like 235 that of the HCWs except that the maximum knowledge score was 27 and the attitude score was Kruskal-Wallis equality-of-populations rank test as appropriate when the data were not 248 normally distributed. The level of significance was set at P < 0.05.

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Ethical considerations: 251 The study was conducted in compliance with Good Clinical Practice standards. Ethical Sixty-three primary healthcare workers who completed the virtual training and post-training 265 assessment were interviewed after and had post-training interaction with clients enrolled for 266 this study out of the 100 that were enrolled at baseline giving a 63% completion rate ( Figure   267 1).

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The socio-demographic characteristics of the HCWs are shown in Table 1. The mean age at 269 the end of the study was 39.2±9.9 years respectively. Females constituted 85% of the group.

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Half of the HCWS were nurses. The mean years of work experience at the end of the study was Thirteen PHC workers who completed the training did complete the post training test after making several attempts within the study timelines. 90%), modes of transmission (>80%), and preventive measures (>93%). Sixty -two (98.4%) of 276 the HCWs were willing to take the COVID-19 vaccine at baseline and all were willing at the 277 end of the study.

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There were no statistically significant differences in the mean COVID 19 knowledge, attitude, 280 and preventive practices scores of PHC workers before and after training, even though they 281 had higher scores (see Table 3). Table 4 shows that health workers more than 30 years had a 282 significantly higher mean knowledge score (28.80± 1.71) than those who were 30 years or less 283 (27.81±2.64). Married PHC workers had higher mean knowledge scores compared with the 284 single. PHC workers in Alimosho LGA had higher mean knowledge scores than those in Ikeja

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LGA. The preventive practice scores of the HCWs were not significantly associated with any 286 attributes of the participants as shown in Table 5. One hundred and thirty-three clients completed the study and were interviewed after their 296 interactions with trained PHC workers out of the 226 that were surveyed at baseline, giving a 297 completion rate of 58.9% ( Figure 2).

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Ninety-three clients were lost to follow up. Most of them had relocated from the study area while some changed their mobile phone numbers and couldn't be reached.
The mean age of clients at the end of the study was 30.9 ± 5.0 years. The majority (78%) earned 299 ₦50,000 or less and 50% had a secondary level of education ( Table 6). The awareness and 300 knowledge of the clients are shown in Table 7 Table 8 shows that there were significantly higher scores in the knowledge, attitude, and 309 preventive practices scores of clients after interaction with trained PHC workers (p<0.001).

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Single clients had significantly higher mean knowledge scores than the married but clients in 311 Ikeja LGA had significantly higher knowledge scores than those in Alimosho LGA after 312 meeting with trained PHC workers. (p<0.05), Table 9. This intervention study set out to determine the knowledge of, attitudes to, and preventive 322 practices of HCWs and their clients at baseline and to evaluate the effect of the training in both 323 groups.

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At baseline, HCWs' knowledge was high, attitudes were positive and preventive practices were 325 good. This high level of knowledge agrees with high levels reported from the UAE, 3 Uganda, 6 326 Ethiopia, 7 and Nigeria. 8,9 It is higher than the levels reported from Yemen 4 and Mozambique. 5

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Nine out of ten HCWs correctly identified the common symptoms such as shortness of breath The clients' levels of knowledge at baseline were fair to moderate. Common symptoms of the 338 disease such as fever, cough and shortness of breath were known although knowledge of more 339 specific ones like anosmia and ageusia was lower. The level of knowledge of the clients is 340 comparable with studies in Pakistan, 22 but much higher than was reported from Kano, northern 341 Nigeria 12 which may be due to lower access to information and lower levels of literacy in Kano.

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The proportion of clients in this study who were aware that an asymptomatic person could 343 transmit COVID-19 was similar to a study amongst mothers of under-five children in Enugu. 13

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In addition, the 70% rate of good preventive practices found at baseline was much higher than 345 the 49% reported amongst pregnant women in Northern Ghana. 14 The vaccine uptake was low   Older HCWs had higher knowledge scores than younger ones in contrast to findings from 363 Ethipia 7 and Nigeria. 15 We posit that the older HCWs were more experienced than their 364 younger colleagues and not just due to cognitive abilities alone. In addition, it may be that the 365 age group category used in our study (30 years) included many more brilliant but young health 366 care workers. The study did not find any association between knowledge and professional cadre 367 of the HCWs unlike what was found in the UAE 3 and Nigeria 9 and this is probably because of 368 the small sample size in our study. The higher levels of knowledge in Alimosho LGAs and the 369 influence of marital status cannot be easily accounted for. We also did not find any significant 370 association between HCWs' socio-demographic characteristics and preventive practices unlike 371 a study from Ethiopia 7 perhaps on account of the small sample size. The finding that single clients had a higher level of knowledge cannot be accounted for. The 382 benefit of clients receiving correct information cannot be overemphasised in the light of 383 conspiracy theories. Contact with health workers who are knowledgeable builds confidence 384 and may lead to sustained utilization of PHCs.

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The efficacy of the intervention is attributable in part to the expertise of the research team, the 386 authentic information in the training materials, the method of delivery, and the willingness of 387 the HCWs to participate on account of their perceived benefits. Virtual training such as this we 388 undertook has numerous advantages. They are low-cost, non-personal, allow for learning at the 389 individual level and pace, are available for continuous learning. They are invaluable for social 390 distancing and for dealing with large groups. This is probably the way to adopt in this era of 391 the new normal.

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This study has shown that virtual training is an effective way to improve the knowledge and 394 skills of health workers who can then impact their clients and bring immense benefit to them, 395 especially in the control of pandemic prone diseases.

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Limitations of the study 397 The positive effect of the intervention amongst HCWs and clients cannot be attributable solely 398 to the intervention as both groups were exposed to other sources of information although not 399 measured which could have contributed to the changes. Mothers were the clients in the study 400 as they were more readily available at PHCs more than men and this limits the generalization 401 of the changes mainly to mothers of children under-five years. The sample size for the study 402 was small. This was in part because the study was meant to demonstrate proof of concept. In              LGA has an estimated population of 460,000 residents. There is a mixture of public and private   HCWs tool sub-scales were: knowledge, α = 0.63; attitude, α = 0.60; and practice, α = 0.86.

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The reliability coefficients for the clients' tool were: knowledge, α = 0.82; attitude, α = 0.67; 186 and practice, α = 0.80. Pre-testing of the study instruments was done amongst 20 HCWs in an

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LGA not involved in the study and who met the eligibility requirements of the study. This 188 was done to test the flow of questions, and clarity of the questions to the interviewer.

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The project was carried out in three phases: baseline (pre-intervention), intervention, and post-  The intervention was developed based on the theory of change model a concept that is used to 198 explain how and why change occurs. 19 20 There are several approaches to the use of the theory.

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It is a process that focuses on the need, the assumptions, the desired interventions, and the Sixty-three primary healthcare workers who completed the virtual training and post-training 268 assessment were interviewed after and had post-training interaction with clients enrolled for 269 this study out of the 100 that were enrolled at baseline giving a 63% completion rate ( Figure   270 1).

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The socio-demographic characteristics of the HCWs are shown in Table 1    There were no statistically significant differences in the mean COVID 19 knowledge, attitude, 284 and preventive practices scores of PHC workers before and after training, even though they 285 had higher scores (see Table 3). Table 4 shows that health workers more than 30 years had a 286 significantly higher mean knowledge score (28.80± 1.71) than those who were 30 years or less 287 (27.81±2.64). Married PHC workers had higher mean knowledge scores compared with the 288 single. PHC workers in Alimosho LGA had higher mean knowledge scores than those in Ikeja

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LGA. ital status and LGA of health workers were statistically significantly associated with 290 knowledge scores. The preventive practice scores of the HCWs were not significantly 291 associated with any attributes of the participants as shown in Table 5. Ninety-three clients were lost to follow up. Most of them had relocated from the study area while some changed their mobile phone numbers and couldn't be reached.

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One hundred and thirty-three clients completed the study and were interviewed after their 301 interactions with trained PHC workers out of the 226 that were surveyed at baseline, giving a 302 completion rate of 58.9% (Figure 2).

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At baseline, more than half (54.2%) of the clients were either 30years or less, with a mean age 304 of 30.5 ± 5.8 years. The mean age of clients at the end of the study was 30.9 ± 5.0 years. The 305 majority (7882%) were employed, most (78%) earned ₦50,000 or less and 50% had a 306 secondary level of education (  Table 8 shows that among those that there were significantlywere significantly higher scores 316 in the knowledge, attitude, and preventive practices scores of clients after interaction with 317 trained PHC workers (p<0.001). Single clients had significantly higher mean knowledge 318 scores than the married but clients in Ikeja LGA had significantly higher knowledge scores 319 than those in Alimosho LGAMarital status and PHC location were statistically significantly 320 associated with clients' knowledge scores after meeting with trained PHC workers. (p<0.05),.

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The single respondents had a better knowledge compared to the married ones. Clients attending 322 PHCs in Ikeja LGA had significantly better knowledge compared with those attending PHCs 323 in Alimosho LGA (see Table 9). Table 10  HCWs.

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Older HCWs had higher knowledge scores than younger ones in contrast to findings from 377 Ethipia 7 and Nigeria. 15 We posit that the older HCWs were more experienced than their 378 younger colleagues and not just due to cognitive abilities alone. In addition, it may be that the 379 age group category used in our study (30 years) included many more brilliant but young health 380 care workers. The study did not find any association between knowledge and professional cadre 381 of the HCWs unlike what was found in the UAE 3 and Nigeria 9 and this is probably because of 382 the small sample size in our study. The higher levels of knowledge in Alimosho LGAs and the 383 influence of marital status cannot be easily accounted for. We also did not find any significant 384 association between HCWs' socio-demographic characteristics and preventive practices unlike 385 a study from Ethiopia 7 perhaps on account of the small sample size. The finding that single clients had a higher level of knowledge cannot be accounted for. The 396 benefit of clients receiving correct information cannot be overemphasised in the light of conspiracy theories. Contact with health workers who are knowledgeable builds confidence 398 and may lead to sustained utilization of PHCs.

399
The efficacy ectiveness of the intervention is attributable in part to the expertise of the research 400 team, the authentic information in the training materials, the method of delivery, and the 401 willingness of the HCWs to participate on account of their perceived benefits. and the support 402 given in terms of data provision. Virtual training such as this we undertook has numerous 403 advantages. They are low-cost, non-personal, allow for learning at the individual level and 404 pace, are available for continuous learning. They are invaluable for social distancing and for 405 dealing with large groups. This is probably the way to adopt in this era of the new normal.

407
This study has shown that virtual training is an effective way to improve the knowledge and 408 skills of health workers who can then impact their clients and bring immense benefit to them, 409 especially in the control of pandemic prone diseases.

410
Limitations of the study 411 The positive effect of the intervention amongst HCWs and clients cannot be attributable solely 412 to the intervention as both groups were exposed to other sources of information although not 413 measured which could have contributed to the changes. Mothers were the clients in the study 414 as they were more readily available at PHCs more than men and this limits the generalization 415 of the changes mainly to mothers of children under-five years. The sample size for the study 416 was small. This was in part because the study was meant to demonstrate proof of concept. In 417 addition, the response rate was not as high as expected. However, this is not unusual in studies 418 amongst health workers 5,15 like the participants in this study who for various reasons could not 419 complete the post-intervention assessment. The lack of a control group is another limitation of 420 the study.